From the Guidelines
The treatment for pulmonary edema should prioritize improving oxygenation and addressing the underlying cause, with initial management including supplemental oxygen therapy and positioning the patient upright to reduce respiratory distress, as well as administering diuretics, such as intravenous furosemide, to reduce fluid overload, as recommended by the European Society of Cardiology guidelines 1. The management of pulmonary edema involves a multifaceted approach, including:
- Supplemental oxygen therapy to improve oxygenation
- Positioning the patient upright to reduce respiratory distress
- Diuretics, particularly intravenous furosemide (40-80mg), to reduce fluid overload by increasing urine output
- Medications to reduce cardiac preload and afterload, such as nitroglycerin (starting at 5-10 mcg/min IV and titrating upward) and morphine (2-4mg IV) to reduce anxiety and preload
- Non-invasive positive pressure ventilation (CPAP or BiPAP) to improve oxygenation and reduce work of breathing, which should be considered in dyspnoeic patients with pulmonary oedema and a respiratory rate >20 breaths/min, as recommended by the European Society of Cardiology guidelines 1
- In severe cases, endotracheal intubation and mechanical ventilation might be necessary Treating the underlying cause is crucial, which may involve:
- Coronary revascularization for ischemic heart disease
- Antihypertensives for hypertensive crisis
- Antibiotics for pneumonia
- ACE inhibitors and beta-blockers for long-term management of heart failure, as recommended by the European Society of Cardiology guidelines 1 These interventions work by reducing hydrostatic pressure in pulmonary capillaries, improving cardiac function, and facilitating the removal of excess fluid from the lungs, thereby improving gas exchange and reducing respiratory distress, as supported by the European Society of Cardiology guidelines 1 and other studies 1.
From the FDA Drug Label
Morphine is also used in the therapy of dyspnea associated with acute left ventricular and pulmonary edema Care must be taken to avoid inducing respiratory depression in such patients.
Morphine (IV) may be used in the treatment of pulmonary edema, specifically for the relief of dyspnea. However, caution is advised to avoid inducing respiratory depression in these patients. 2
From the Research
Treatment Options for Pulmonary Edema
The treatment for pulmonary edema has shifted from diuretics to vasodilators combined with noninvasive positive airway pressure ventilation and rarely inotropes 3. The following are some treatment options:
- Vasodilators such as high-dose nitrates to reduce systemic vascular resistance and decrease left ventricular diastolic pressure 3
- Noninvasive positive airway pressure ventilation to reduce the workload on the heart and improve oxygenation 3
- Inotropes to increase cardiac contractility and improve cardiac output 3
- Diuretics such as furosemide to reduce fluid overload, but their use should be cautious as they can cause hypovolemia and worsen pulmonary edema 4
Pharmacological Therapy
Pharmacological therapy for pulmonary edema includes:
- Diuretics (89% of patients) 5
- Antibiotics (84% of patients) 5
- Acetylsalicylic acid (81% of patients) 5
- Nitroglycerin, which has been shown to be beneficial in the management of presumed pre-hospital pulmonary edema 6
- Morphine, which may not add anything to the efficacy of nitroglycerin and may be potentially deleterious in some patients 6
Management Strategies
Management strategies for pulmonary edema include:
- Sitting the patient up with the legs dependent to reduce venous return and decrease pulmonary congestion 7
- Administering oxygen by nasal prongs to improve oxygenation 7
- Giving sublingual nitroglycerin to reduce systemic vascular resistance and decrease left ventricular diastolic pressure 7
- Using small doses of morphine to reduce anxiety and discomfort 7
- Rotating tourniquets on the limbs to reduce venous return and decrease pulmonary congestion 7